Nice presentation For midwifery. Presented under supervision of Dr. Stella Ass. Lecturer at Muhas Presenter John Marco Registration number 2019-04-13514 BSc. Midwifery Third year student at Muhimbili university of health allied science (MUHAS). Topic: Abnormal Uterine action.

1. MUHIMBILI UNIVERSITY OF
HEALTH AND ALLIED
SCIENCES
SCHOOL OF NURSING
Programme: BSC. MIDWIFERY
Course: Emergence obstetrics
Tittle: Abnormal uterine action
Presenter: JOHN MARCO (2019-04-13514)
Facilitators: Dr. Stella Emmanuel

2. Objectives




At the end of this session students should
manage to
Explain different disorders of abnormal
uterine action
Identify signs and symptoms of different
abnormal uterine disorders
Make diagnosis on different abnormal
uterine action disorders
Give a correct management of abnormal
uterine action disorders

3. Flashback to normal uterine action
•





Characterized by the following
Well coordinated uterine contractions
Cervical dilation ≥1cm/hr for nulliparous and
1.5 cm/hr for a multiparous woman
Effectively end in vaginal delivery
Has good polarity – when upper segment
contract lower segment relax
Initiated only by single peacemakers (situated
at each cornua of uterus) in a coordinated
patten

4. Flashback to normal uterine action






Contraction intensity diminishes from top
to bottom
Contraction duration lowers as wave
propagates away from the peacemakers
Uterine activity is normally measured by
Basal tone (5-20 mmHg) but Minimum
uterine pressure required to dilate the cervix
is 15 mm Hg over the baseline
Peak (active) pressure (50-60mmHg)
Frequency 1-5 contractions per 10minutes)
Resting tone of 10–15 mm Hg.

5. Flashback to normal uterine action

6. Abnormal uterine action
(syn. disordered uterine action)

7. Abnormal uterine action
•
•
•
Any deviation from normal uterine contraction
patens disrupting the course of labor
It can be classified in to
Primary dysfunctional labor;- is when cervix
dilate by less than 1cm/hr following normal
latent phase. Uterine activity is governed by
emergence of other peacemaker foci rather
than single dominant cornal peacemaker.
Corrected by Amniotomy or argumentation by
oxytocin

8. Abnormal (disordered) uterine
action
• Secondary arrest ;- dilatation of labor
decreases or stops after normal onset of
active phase of labor
General causes of abnormal uterine action
Unknown causes

9. Risk factors
•
•
•
•
•
•
Over distended uterus eg. Twin pregnancy
Emotional factors eg stress, anxiety
Constitutional labor (obesity)
Contracted pelvis
Malpresentaion
Injudious use of analgesics, oxytocics and
sedatives

10. Types of abnormal uterine action
•





Normal polarity
Hypertonic
Precipitate
labor
Tonic uterine
contraction
and retraction
Hypotonic
Uterine inertia
•





Abnormal polarity
Spastic lower
segment
Asymmetric uterine
contractions
Contraction ring
Generalized tonic
contraction
Cervical dystocia

11. Normal polarity
•


Uterine disorders with normal polarity
include
Hypotonic
Hypertonic

12. Hypotonic contraction (uterine
inertia)
•
•
–
–
–
–


Uterine pressure during contraction
decreases to lower than 25mmHg while the
contraction patterns in labor are maintained
Its uterine contractions are characterized by
Increased interval
Good relaxation between contractions
Short duration
Low intensity
Although is the common abnormality but less
serious.
It can occur at any stage of effective labor or
even at the beginning of labor (can be
primary or secondary).

13. Diagnosis
•
•
•
•
•
Abdominal exam reveals
Less hardening of uterus during
contractions felt on abdominal palpation
Fetal parts are well palpable
FHR is normal
Less pain during contraction
Uterine walls easily identified at the peak
or acme of a pain

14. Vaginal exam
•
•
Membrane usually intact
Poor cervical dilation
It is accompanied by malposition,
malpresentation, deflexed head or
contacted pelvis

15. Midwifery Management
•
(1)
(2)
(3)
(4)
(5)
Vaginal delivery
(A) General measures:
To keep up the morale of the patient. Maternal
stress, pain and anxiety appear to inhibit
uterine contractions through release of
endogenous catecholamines.
Posture of the woman is changed. Supine
position is avoided.
To empty the bladder, catheterization is
made.
To maintain hydration by infusion of Ringer’s
solution.
Adequate pain relief

16. Midwifery Management…
•
•
•
(B) Active measures:
Acceleration of uterine contraction can
be brought about by low rupture of the
membranes followed by oxytocin drip.
The drip rate is gradually increased until
effective contractions are set up
The drip is to be continued till 1 hour
after delivery

17. Surgical Management…
•
•
•
cesarean section:
C/S to done when the following are
identified
Presence of contracted pelvis
Malpresentation
Evidences of fetal or maternal distress.

18. Complications
•
•
Maternal exhaustion and/or
Fetal distress (unusual and appear late)

19. TONIC UTERINE CONTRACTION AND
RETRACTION
(Syn: Bandl’s ring, Pathological retraction
ring)
•
•
•
•
This type of uterine contraction is
predominantly due to obstructed labor.
Pathological anatomy of the uterus:
There is gradual increase in intensity, duration
and frequency of uterine contraction.
The relaxation phase becomes less and less;
ultimately a state of tonic contraction develops.
Retraction, however, continues.
HYPERTONIC NORMAL POLARITY

20. TONIC UTERINE CONTRACTION
AND RETRACTION…….
•
•
•
The lower segment elongates and becomes
progressively thinner to accommodate the
fetus driven from the upper segment
A circular groove encircling the uterus is
formed between the active upper segment
and the distended lower segment, called
pathological retraction ring (Bandl’s ring).
Due to pronounced retraction, there is fetal
jeopardy or even death

21. TONIC UTERINE CONTRACTION AND
RETRACTION….
A=Normal labour B=Tonic uterine contraction
Note
the circumferential
dilatation and
progressive stretching
of the lower
segment with
corresponding
thickening of
the upper segment
and rise in the level of
retraction ring
following obstruction

22. TONIC UTERINE CONTRACTION
AND RETRACTION..
•
•
•
In primigravidae
Further retraction ceases in response to
obstruction
labor comes to a stand still—a state of
uterine exhaustion.
Contractions may recommence after a
brief period of rest with renewed vigor.

23. TONIC UTERINE CONTRACTION
AND RETRACTION..
•
•
Multiparae
retraction continues with progressive
circumferential dilatation and thinning of
the lower segment.
There is progressive rise of the Bandl’s
ring, moving nearer and nearer to the
umbilicus and ultimately, the lower
segment ruptures

24. Clinical features:
(1)
(2)
(3)


Patient is in suffer from continuous pain
and discomfort and becomes restless
Features of exhaustion and ketoacidosis
are evident
Abdominal palpation reveals;
Upper segment is hard and tender
Lower segment is distended and tender

25. Midwifery Management:
•
•
•
•
Prevention management
Partographic management of labor
Early diagnosis of malpresentation, and
disproportion
Plan for cesarean section, can prevent this
condition completely when done early
Internal version (turning of fetus) is
contraindicated

26. Midwifery Management:
•
•
•
•
•
•
Treatment:
Rupture of uterus is to be excluded
Correction of dehydration and ketoacidosis by
infusion of Ringer’s solution
Adequate pain relief (metoclopramide 10mg im
or pethidine 50-100mg im)
Parenteral antibiotic is given (Ceftriaxone 1 g IV)
Cesarean delivery is done in majority of the
cases.
Rupture of uterus must be excluded before
attempting destructive operation.

27. PRECIPITATE LABOR (short labor)
•
•
•
A labor that occur when the combined
duration of the first and second stage is
less than 3 hours.
It is common in multiparae and may be
repetitive.
WILL BE DISCUSSED IN MORE DETAILES
IN NEXT SESSION
HYPERTONIC NORMAL POLARITY……

28. ABNORMAL POLARITY/
INCOORDINATE UTERINE ACTION
•
–
–
–
–
•
•
•
Is hypertonic state of the uterus arising from
any uterine condition such as
Spastic lower uterine segment,
Asymmetrical uterine contraction,
Constriction ring or generalized tonic
contraction of the uterus.
Cervical dystocia
All these states are collectively called
incoordinate uterine action.
Uterine tonus is elevated.
It usually but not must appear in active stage
of labour

30. Effect of incordinate uterine action
•
•
•
•
Increased frequency and/or duration of
uterine contractions cause rise in baseline
tone and thereby diminish circulation in the
placental intervillous space.
These contractions fail to make progressive
cervical effacement and dilatation.
Frequent contraction of low amplitude
causes elevation of basal intrauterine
pressure.
There is often maternal discomfort.

31. Effect of incordinate uterine action..
•
•
•
•
Pain is present before, during and after
contractions.
This results in fetal hypoxia in labor.
Placental abruption is often associated with
high baseline tone (> 25 mm Hg). On CTG the
FHR shows reduced variability and late
decelerations (Figs 25.2B and C).
Uterine hyperstimulation due to oxytocics
(oxytocin, prostaglandins) are often
associated with fetal tachycardia (fetal
adrenergic activity) due to fetal stress.

32. management
•
•
Aminotomy with or without oxytocin
augmentation when the women is in the
active phase of labor.
Conservative management is done if it
occurs in the latent phase.

33. SPASTIC LOWER SEGMENT
•
•
•
•
•
During the uterine contraction:
Fundal dominance is lacking and often
there is reversed polarity
The pacemakers do not work in rhythm;
The lower segment contractions are
stronger;
Inadequate relaxation in between
contractions;
Basal tone is raised above the critical level
of 20 mm Hg

34. Diagnosis:
•
•
•
•
–
–
The patient is in agony with unbearable pain
referred to the back. There are evidences of
dehydration and ketoacidosis;
Bladder is frequently distendedand often
there is retention of urine; distension of the
stomach and bowels are visible;
There are premature attempts to bear down;
Abdominal palpation reveals:
Uterus is tender and gentle hardening of the
uterus with pain,
palpation of the fetal parts is difficult,

35. Diagnosis:
•
•
–
–
–
–
Fetal distress appears early;
Internal examination may reveal:
Cervix which is thick, edematous hangs
loosely; not well applied to the presenting part,
Inappropriate dilatation of the cervix,
Absence of the membranes,
Meconium stained liquor amnii may be there.

36. Management :
•
•
•
There is no place of oxytocin
augmentation with this abnormality.
Cesarean section is done in majority of
cases.
Midwife should make a prior correction of
dehydration and ketoacidosis by rapid
infusion of Ringer’s solution

37. CONSTRICTION RING
(Syn: Contraction ring, Schroeder’s ring):
•
•
It is one form of incoordinate uterine
action where there is localized myometrial
contraction forming a ring of circular
muscle fibers of the uterus. It is usually
situated at the junction of the upper and
lower segment around a constricted part
of the fetus usually around the neck in
cephalic presentation.
It may appear in all the stages of labor but
usually reversible and complete

38. Schroeder’s ring

39. Causes
•
(1)
(2)
(3)
The common causes are:
injudicious administration of oxytocics,
Premature rupture of the membranes,
and
Premature attempt at instrumental
delivery.

40. Diagnosis:
•
•
•
•
Diagnosis is difficult. It is revealed during
cesarean section and during manual
removal in the third stage.
The ring is not felt per abdomen.
Maternal condition is not much affected
but the fetus is in jeopardy because of the
hypertonic state.
Uterus never ruptures

41. Treatment:
•
•
•
Delivery is usually done by cesarean section.
The ring usually passes off by deepening
the plane of anesthesia otherwise the ring
may have to be cut vertically to deliver the
baby.
The difficulties faced during normal
removal of placenta (third stage) can be
overcome by using deep anesthesia that
relaxes the constriction ring.

42. CERVICAL DYSTOCIA:
•
•
–
–
–
Failure of cervical dilatation
Mostly caused by lack effective stretching
force by the presenting part. may be due
to—
(a) Inefficient uterine contractions.
(b) Malpresentation, malposition
(c) Spasm (contractions) of the cervix.

43. Types of cervical dystocia
•
•
•
•
Primary:
Commonly observed during the
(i) First birth where the external os fails to dilate,
(ii) Inefficient uterine contractions.
Secondary cervical dystocia
Results from excess scarring or rigidity of the
cervix due to effect of previous operation or
disease. Example
(i) Post-delivery
(ii) Postoperative scarring
(iii) Cervical cancer.

44. Midwive’s concern:
•
•
•
In presence of associated complications
(malpresentation, malposition), cesarean
section is preferred.
If the head is sufficiently low down with only
thin rim of cervix left behind, the rim may be
pushed up manually during contraction or
traction is given by ventouse (vacume
extraction).
When the cervix is very much thinned out but
only half dilated. Dührssen’s incision at 2
and 10’O clock positions followed by
ventouse extraction is quite safe and
effective.

45. GENERALIZED TONIC
CONTRACTION (Syn: Uterine tetany):
•
•
•
•
•
Retraction occurs involving whole of the
uterus up to the level of internal os.
There is no physiological difference between
active upper segment and passive lower
segment of the uterus.
The whole uterus undergoes a sort of tonic
muscular spasm holding the fetus inside
(active retention of the fetus).
Usually there is no risk of rupture uterus.
New pacemakers appear all over the uterus

46. Causes:
•
•
•
Cephalopelvic
disproportion
Obstruction
Injudicious use of
oxy

47. Clinical features:
•
•
•
•
Prolonged labor with severe and continuous
pain.
Abdominal examination reveals the uterus
to be somewhat smaller in size, tense and
tender.
Fetal parts are neither well defined, nor is
the fetal heart sound audible.
Vaginal examination reveals jammed head
with big caput, dry and edematous vagina

48. Management :
•
•
•
•
•
Correction of dehydration and
ketoacidosis by rapid infusion of Ringer’s
solution
Antibiotic—to control infection
Adequate pain relief
Hypercontractility (tachysystole) may be
induced by oxytocics (>5 contractions in
10 min).
It may occur in spontaneous or with
stimulated labor.

49. Management :
•
•
•
•
Persistent tachysystole with FHR
abnormality can cause fetal hypoxia.
It can be managed by tocolytics
(Terbutaline 0.25 mg SC).
Oxytocin infusion should be stopped.
Cesarean delivery is done in majority of
the cases, especially when obstruction is
suspected

53. Midwife roles in Preventivion of
Dystocia due to Abnormal Uterine
Action:
(1)
(2)
(3)
Quality antenatal care, emotional
support to be parturient and close
monitoring of labor can reduce
abnormal uterine action.
Induction of labor should be judicious,
especially when the cervix is
unfavorable.
Amniotomy in the latent phase or as
a routine procedure is to be avoided.

54. Midwife roles in preventivion of Dystocia
due to Abnormal Uterine Action:
4) During the course of labor the woman
should be given adequate moral
support, rest and analgesic. Her
hydration should be maintained.
5) Management of labor should be
plotted partographically so that any
deviation from the normal is detected
and managed early

55. SUMMARY
•
•
•
•
•
Abnormal Uterine Action is due to
development of abnormal polarity on the
uterus.
It may manifest as uterine inertia (common)
or hypertonic dysfunction.
Hypertonic dysfunction may end in either
formation of Bandl’s ring or precipitate labor.
Incoordinate uterine action can affect the
health of both the mother and the fetus
adversely.
It is important to detect AUA early and to
institute management appropriately to
reduce maternal and neonatal morbidity and
mortality.

56. Reference
•
•
DC Dutta’s Textbook of OBSTETRICS
including Perinatology and Contraception
Eighth Edition 2015
Dorairajan G. (Ed).(2022) management of
normal and high risk labor during
chirdbirth (1st ed).CRC press http://doi.
org/10.1201/9781003034360

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